Biopsychosocial Assessment
Initials: Age: 34Yrs Weight: 78Kg Ethnicity: Black American
Race: African American Allergies: None
AWB
Occupation: Accountant Family Constellation: Married with 2
children ages 5 and 8
Living Situation: Lives with spouse and children in a rented house
Presenting complaint: Difficulty in sustaining social relationships and frequent anxiety,
affecting work and family life.
History of present Symptoms started in early adulthood, worsening over the last five
illness: years. Patient reports impulsivity, mood swings, anxiety and strained
relationships with family and friends.
Characteristics of
Personality Disorder
The characteristics of a Patient displays reduced empathy and fails to consider others’
personality disorder are perspectives, leading to conflicts at home and in the workplace. This
impairments in self and significantly affects his social functioning.
interpersonal
functioning, and the
presence of pathological
personality traits. To
diagnose a personality
disorder, the following
criteria must be met:
•Substantial
impairments in self
(identity or self-
direction) and
interpersonal (empathy
or intimacy) functioning
•One or more
pathological personality The patient is highly impulsive and easily irritable, mostly when under
trait domains or trait stress. He also notes that he experiences mood swings, sometimes
features happy, but mostly sad.
•These impairments in
personality functioning Symptoms have persisted over time and across different settings such
and the individual’s as home and the workplace. Symptoms began in early adulthood with
personality traits are the patient reporting increased psychological imbalance.
relatively stable across
time and situation
•These impairments in
personality functioning These traits and impairments are atypical for developmental stage and
and personality trait culture.
expression are not
considered as normal for
the individual’s
developmental stage or
socio-cultural
environment
•These impairments in
personality function and There is no evidence that the impairments are as a result of medical
trait expression are not condition and substance abuse.
due to the physiological
effects of a medical
condition or substance
(APA, 2013).
Patterns of behavior
(self-harm, alcohol, drug History of self during teenage years, but no recent incidents.
use, Addiction Occasional drinking, mostly on weekends and no use of illicit drugs.
(shopping, gambling, The patient reported no major addictions.
pornography, video,
gaming, etc.):
Shoplifting:
None reported
Legal issues:
None reported
Interpersonal
functioning and The patient reported issues in developing trust in relationships. Also he
relatedness: reported feeling isolated and misunderstood, leading to his withdrawal
from social relationships. This has strained his relationship with family
and friends as he reports impulsive reactions.
Alterations in cognition:
Occasionally suspicious, particularly regarding others’ intentions,
exacerbating social conflicts and immensely contributing to
interpersonal conflicts.
Current and recent
stressors:
The patient reports that he was recently promoted, increasing his
responsibility, thus causing immense stress. He has also recently had
conflicts with his spouse over parental responsibilities, propagating
psychological tensions.
Current coping skills:
Reports reading as a coping mechanism. Other mechanisms he reports to be
involved in are exercising and meditation.
Spirituality and/or
religion:
Christian
Client and family’s
perception of problem:
Believes that mood swings and relational issues are stress-associated. Family
reports concerns of impulsivity and irritability that affects the home
environment.
Past medical history
(medical history,
treatment and outcomes,
recent and past
hospitalizations,
surgeries):
Family medical history:
Medications (side
effects, adverse side
effects, and treatment
response) INCLUDE
BELIEFS about
medications
Non-prescription
drugs/OTC:
Substance use history
(for each substance,
identify the type and
details to include:
duration, frequency, last
use; blackouts;
withdrawal seizures;
drug-related psychosis).
Legal, psychosocial,
physical, interpersonal,
and occupational
consequences.
Smoking history:
Alcohol use:
Marijuana use:
Illicit drugs:
Herbals:
Complementary
treatments:
Include exposure to
prescription opioids
(reasons for use, pain,
duration, frequency etc.)
Psychotropic
medications, side effects,
adverse side effects, and
treatment response:
Past psychiatric history
(psychiatric
history/treatment and
outcomes, recent and
past psychiatric or
substance abuse
hospitalizations,
residential or outpatient
treatments):
Family psychiatric
history and/or substance
use history:
Sociocultural history
(family and social
history, work history,
current employment,
volunteer work, legal
history, active and past,
current support system,
marital status, and
children):
Trauma history:
Trauma exposure
(childhood abuse or
neglect, rape or sexual
assault, emotional abuse,
domestic violence,
military/combat service,
and natural disasters,
historical/political
trauma):
History of head injury,
loss of consciousness,
seizures:
COMPREHENSIVE
TREATMENT PLAN:
INCLUDE
EVIDENCED- BASED
THERAPEUTIC
MODALITIES FOR
THE IDENTIFIED
PERSONALITY
DISORDER
